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tv   Cost of Health Care  CSPAN  February 3, 2013 2:00am-4:10am EST

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must move forward, we also know that real progress cannot be made until the fatally flawed formula is repealed once and for all. this long-standing and lingering problem perpetuates the annual threat of cuts of that destabilize physician practices and erodes confidence in medicare and limit access medict access for patients. these realities posed obstacles to widespread crop -- widespread adoption of the models needed to reinvigorate our medicare program in the service of 47 million americans. our work to build a strong and sustainable medicare system is one effort by the american medical association in making a better future for physicians, our patience and our nation. we have embarked on a five-year
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strategy focused on three critical areas to the future of health care. first, to improve patients' health outcomes and reduce health costs. second, to the accelerate innovations in medical education, to align physician training and education with the kind of environment they will experience what their education is through. and three, to enhance practice sustainability by helping physicians adopt models that make sense for their practices, their patients, and the communities they serve. these are big and ambitious goals but they are the foundation upon which we coat -- we will contribute at fell the mission of the ama, to promote the arts and science of medicine
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and the betterment of public health to meet the challenges of today's health care environment, it has to be done as a group. we must all participate to make a difference. this morning, the national journal has gathered experts to share their ideas on what is right and wrong with medicare, why we must adapt and adopt now so we can continue to accomplish that which cannot be accomplished by any one sector of the health care industry alone. thank you for being here this morning. i look forward to the discussion, particularly given the nature of the participants. thank you very much. >> thank you. while we are setting up here for panel, i want to give you a rundown of this morning's program. we will have three distinct
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panels. first is a panel of thought leaders in health care, followed by physicians and experts who will respond to what has been discussed and provide context for all of us. moderate all three panels today is maggie fox. she was the managing editor of healthcare and technology at national journal she was the global health and science editor for reuters. she is -- has also served as a correspondent for a variety of news organizations. she covered tenement in china and is one of the few people to have interviewed gadhafi. dr. len nichols of george mason university and the honorable gil wilensky, senior fellow at
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project hope. >> good morning. thank you for being here. i would like to thank the panel for being here. these are three of the deepest thinkers on health policy issues in the country. i am representing the shallow end of the scale here to balance it out. so you can see the stage is tipping pretty hard. [laughter] i think dr. james madara set a good tone in his opening comments. that is a good way to get into the discussion, to ask about the points he raised, especially the str, the doc fix, and
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transition into ways we can get physicians, patients and insurers more on board with improving medicare. and how medicare can lead the way. i know all of you have very specific spot on this subject. dr. paul ginsburg, what is the best way to get positions better involved in improving care via medicare? >> the main strategy long term is not so much to have individual positions interact with medicare in new ways but to have positions join organizations working for hospitals where the organizations would interact with medicare. contacting with it as an accountable care organization
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rather than some how chris king medicare -- rather than somehow positioning medicare into a pretzel. nk we need an organizational interface. >> but organization, what do you mean? >> if to be a medical group, -- it could be a medical group, primary-care physicians, an independent practice association, or even a hospital would implement relationships with physicians or contractual relationships with physicians
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were and of it -- where an individual can accept some of the risks and be accountable. i see the future of physicians with medicare as developing organizations they would have their allegiance to and their accountability towards and the organizations would interact with medicare. >> this is an area where there is a lot of agreement among policy people and with a practicing physician community. that is for way too long, health care in the united states has been a volume driven and not enough attention has been paid on how to improve quality and efficiency.
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in the most of medicare, in terms of payment, there were bundled payments. rather than having medicare pay for each individual service provided, there is a larger payment that covers a variety of services. the thinking was that would allow the clinicians or institutions to focus on the general purpose of the visit and not be too focused on each individual item. physicians have long been in a different world. they have stayed with an
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aggregated fee schedule, attempting to keep spending in the aggregate. everybody ended up being frustrated. physicians, because they felt constrained. taking care of somebody with complex diabetes, you want to spend time counseling them. you do not necessarily want to have to focus -- can i find something i can build for >? ? the best way to help physicians take good care of their patients and not fight the billing system is really the
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issue we're dealing with. directionally, there is a lot of agreement. the pacific's -- the specifics, where there are groups of physicians or the physicians are tied to hospitals or are a part of a larger integrated delivery systems, they can focus on taking care of patients and have the measurement of performance seem more fairly measured in terms of whether or not their patients have good outcomes. how to make that transformation is where we are stuck. lots of different ideas, figuring out what actually
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works, will be the no. 1 job for the next few years. and not an easy one. it will be getting our hands on data, deciding how we have to adjust for different populations we are under consideration. the positive way to look at this is there really is a lot of cream we have to find a smarter way to provide better, more efficient health care. >> when it comes to point out what the problems are, the hard part is figuring out what to do it into reality.
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given our current political climate, what are some of the realistic goals you think can be achieved? rex -- >> first of all, you should always buy good bourbon. [laughter] what gil was describing was how to get physicians engaged in a world that we now. no one has shown physicians the map. it will probably be different in south carolina than rural arkansas and boston. this is a big old diverse country. you want to listen to physicians. dr. james madara said it well. we need to get that away because we cannot focus on what we need to do. the second thing is to listen to what they complain about.
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what i hear is how much time is spent doing documentation that does not improve patient care. there is a term for the economics. it is called apple should, we need to fix that -- it is called bullshit. we need to fix that. [laughter] scheduled, fee there are 1300 members of [indiscernible] how many can you name? the point. -- that is the point. i think we need to focuse more on responding to enjoining local initiatives. one of the most exciting pieces of the affordable care act is
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the innovation challenge grants were they basically say to the country, you tell us how you would document what you're doing to improve patient care at lower costs. 3000 applications. that means 3000 different groups came up with ideas about how to make our system better. where they live and work? my favorite one is rochester, new york carried -- new york. they have everyone at the table. every clinician i have met just want to be paid for what they do in one way. they want one set of incentives, costa reporting, feedback loops. had the focus on patient care if
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you do not get the structure payments. we need to figure out how to join local initiatives. just have medicare john the party. bring their data impossibility to adjust and adapt the incentives structure that the locals have to get off -- have figured out. re at a verye aer at a vey exciting time. i'm optimistic for a change. the leadership of medicine and hospitals and insurers are all saying the same thing about what we want to get away from. we want to get away from fragmented, volume driven care.
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it will take awhile to figure it out. my sense is this will be a journey where something is working, we will get rid of it and go back to where we were. if it is not working, we will be working on that. >> there is such a division among the different stakeholders' terry >> -- among the difference stakeholders. >> the part that is what is that most people, starting in 2014, will have insurance coverage. this has been a serious problem at all levels for the country. it has been embarrassing.
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it is difficult for the people who provide care when you get sick. it will be important that we substantially reduced, not completely eliminate, the number of people without insurance coverage. with the affordable care act has done is to set up an environment in which there is support and encouragement for new innovations. the challenge grant is being sponsored. the danger i worry about is that -- the same factored silo
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paying for of volume, not performance, system that we have had. there are some very small movements. in 2015, there is a volume modifier that will treat physician payments. these are not large changes. tweak. are little we drive the changes that are bubbling up to become part of medicare and medicaid reimbursement. that is going to take some doing.
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we had experiments in the past where we gave -- it is harder to imagine what rochester as pilaf say in miami. >> whose responsibility is it to drive these things? >> that is one of the hardest questions. cms, the advantage of medicare and medicaid, is that when the moves forward, and moves forward in a major way. there he is constrained -- there
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are constraints. the private sector does not have to play mother may i. if they did not, there would be violating the anti kickback provisions. the private sector has been doing accountable care organization kept activities for the last four or five years. the point is that the public and private sector will have to figure out how to do this jointly. to be into the dissent -- to feed into the decision making of the public sector. the national committee for quality and assurance provided
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interesting model. by being fundamentally private, they had the government at the table without all the constraints of having to do it as a government activity, which means every single change has to go to the procedures act. regulations have to be written. they have to go to a very complicated procedure. finding a way for the public and private sector to come together and when the results seem clear for a -- it is going to be this figuring out how to move together. there are things each sector can do best. >> i want to go back to who's
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responsible. the answer is all of us are responsible. you have to figure out how to get her by the table. at the end of the day, people to not trust helped plant. the situation can enable every doctor to do so b ut i will also say physicians have to take ownership of the su we have to promidt.
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the only person who completes that balancing act. a lot of what they know now is more is better. more is not always better. >> more was better when that's how youpaid economically. >> making sure we can hold accountable the major payers -- the major players. they feel they are part and parcel activity. not something we are known for here.
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>> patient involvement three patients cannot just sit back and be -- >> one of the limiting factors of the accountable care organizations is a fundamentally do not include the patient's in any direct way. i think that is a fatal flaw. they may be awaiting to get physicians to work together -- there may be a way to get physicians to work together. if we can i get the patients involved, it will be hard to sell this problem. many have physicians much more involved than they have been at
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some time is but if we do not get the patients in their actively. >> we missed a huge opportunity by not building in patient incentives in the accountable care organization structure. we should definitely have that sort of thing. >> despite everything that has happened in health care in private insurance. medicare beneficiaries. perhaps from strong successful
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private insurance, shelling constructive ways for an engaging patient. >> can have some specific examples? one barrier is education. the program evolved from large employers and pairs of the telecast, they have a strategy and number of years ago. the also included a financial incentive to patients who were part of this group, recognizing compliance is a major issue. there was not just encouraging.
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some said are offering, if they comply with various lummis strategies, had engaged in exercise and nutrition classes. activities to encourage the cessation of smoking. it is not only stopping in negative city --
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try to buy -- try to provide information with rewards and recognition to make them feel they are part of having better health outcomes. not this passive participant the other people do things to but having good health and good health outcomes is something you as a patient can participate in. getting people to focus on the act come, not that it put someone else does to them. it means starting early in the schools. we see glimmers of hope with the emphasis on better nutrition and in school lunch programs.
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starting very young with the importance of nutrition and exercise and not smoking, etc. >> we need to get consumer patient input in the design of processes and structures. there was a surgery wing in the brought in patients who had been involved in that was far more effective. listen to patients in your office. i was at a conference of people doing medical homes across the country. the was a patient in the room. the patient talked-about
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[indiscernible] it is about learning to listen and bring in that listening to the design of your process to generate better care and get them more engaged. >> we will open it up to questions from audience. there are mics. please say who you are and stand up to ask your question. there are a couple over here. practicing primary care physician. we have talked about lowering costs and improving results. everywhere else they have health care for everyone.
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there's somebody here from the embassy of the netherlands. why don't we ever talk about that? that as a model that is up and running. we do talk about and spent 2009- 2010 trying to decide what would work for this country. i do not know whether my past will work very well or not. it goes a long way to expand insurance coverage to almost all legal citizens in the u.s.
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it will open up another group of people left out of the affordable care act. doing it in a way that helps the stivers country is tricky. it is not the other countries do not have this issue. but think about health care system. that as a closer model than thinking about the health care system that works for the netherlands. me have taken one step ahead the terms of expanding coverage. we are still struggling. it will take a lot of changes
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over the next decade or two. we have been having some of these discussions and that the medicare. health care reform 1.0. hang on. the rest will come to the next decade or so. >> we have had problems with positive element. we hve identified a range of tactical issues -- how to engage -- that can cross border.
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i think they are learning from us as well. thre are opportunities here that did not exist before. >> another question right here. >> i am a physician and health policy communications consultant. i was involved in a similar project in cincinnati were they brought in the stakeholders. with 5000 hospitals doing this, it will be a challenge. the re and morre of
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provisions become effective, there will be a lot of backlash. don't do this incentive for that report acquirement. >> i think we are hearing it now. that is their job. in some level, that is what we need. we rwote 1.0. we need 3.0. i would say, i take your point about cincinnati. " we do not need the whole country to do it on our own three if you work on -- figure out what works.
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it will be hard but figure out what works and spread that. the pit which model works for you. it will be different. >> i thik this will be a fun period because a lot of this is voluntary. it is pretty much all voluntary for now terry >> -- all vol untary for now. >> only working with volunteers constrains the way this could be done.
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we have to assess what is working and is it -- and transition to something that is more mandatory. this is where i think sgr will come in. it has been a major policy error when it was developed, creating an incentive structure where the people who were at risk had no way of succeeding and asking for the schedule i ha-- no way of succeeding. it is a way to bring more physicians into new ways of delivering care.
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we think we know the way to go. if you will work this way in participate in these new organizations, that you are excused from sgr. it will take a budget hit and these members of congress can say we figured out how to deliver care more efficiently. we are ready now to transition to take a hit from sgr. >> the losers in the system will start screaming bloody murder. i can tell you now what they are going to say. it is the evil government or private payers keeping me from providing you. it provides a -- will be real winners and real losers. they will be lobbying grenads at
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every opportunity. i am hopeful if we have better information and statistics, and we can try to push back. it is not so that health care -- helped is changing because of this. >> we have run out of time for any more questions. and for this panel fo deep -- of deep thinkers who are clearly deep talkers as well. thank you so muchl . our next panel will be from physicians. back.see if they kick you thanky ou so much. [applause] >> thank you.
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we will welcome our second panel which will focus on physicians. while we set the stage, i will announce who will be joining for panel #23 ibm dr. thomas, edward murphy, and dr. grace carol. >> you guys have a lot of water to work from. worka lot of fodder to from. fix a lot offix this trouble? >> i think the sgr is clearly an
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issue around access for patients who have medicare for their insurance covers. i do not think fixing it fixes the problem terry -- fixes the problem. to get the physicians involved is the key to this. the key part of it. from our perspective, the way you do that as you provide them with systems but you do not learn the -- did not load the problem. you provide them with systems, the systems to do quality measurement.
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he supports them in doing the management that has to be done. we have to get away from the individual encounter with the individual doctor. it has to be a team of people. mead nurses, physicians assistants, -- it means nurses, physicians assistants, etc., working together to care for the patient in the doctor's office and when the patient is at home. and in other areas of the medical care system. we have to develop systems to do that. in our world, we have done some of that. we have generated some systems that have improved quality.
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we had some interesting relationships with medicare advance providers who were willing to fund the upfront those systems because they had seen. i will take a little issue when he referred to low and primary care. at the primary care doctor is the key to all of this. the relationship with the primary care doctor and the staff, of the doctor's to help get the patients involved.
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the primary care physicians of the nexus for this going forward. >> you are at the ground level actually doing this. is that right? >> i do practice medicine. i am a general internist. an 89-year-old patient i had been sick for 29 years, she drove and lived alone. -- i had been seeing for 29 years, she drove and lived alone. calledghrt t a viru and her friend and took he =r to the emergency room. when she showed back up to my office last week, she was in
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wheelchair and her sn -- son's were trying to figure out what to do with her care. i bet you that was 40,000 minimum of profit. when we talk about care, we think about our patients. she did i get good health care, in my opinion. everybody makes a lot of money. it will require far more than that. i am we decided to go for it.
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a year-and-a-half ago, we said we are going to change all of our contracts, invest at least $25 million and figure out how to contract with everybody in a new system. the interesting thing about that is how hard that is. it is hard to get capital if you are an independent group. this city back into the 20th century which was about technology. it is hard to bring the per se aong.--the paryeryers we are still in that proft model. my organization has not been that hard so long as we keep
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telling stories about patients, like the one i just did. if we are going to lead this, it goes back to the relationship between physicians and patients and what we went to medical school to begin with. the other thing those happening and that in 1965 -- thing that we hadppening in 1965, tv with antennas on them. we do not talk about " any to do to get -- the things we need to do to get --
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-- tod to make ia make a model. >> dr. murphy, you are nodding your head. >> yes. that is very observant. i'll ask a question and answer it too so i guess it is a rhetorical question. [laughter] i have heard great unanimity among the first five speakers about what you have to do, what the solution is. a fair question this, if there is that level of unanimity about
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direction we should take, why aren't we further down the road? >> the reason is and into my opinion that the body of work we described is fundamentally different than the last hundred years of medicine has talked. we -- driven by the reimbursement system. individual, discreet, billable transactions. cornyn complex diseases. management of those problems that not lend itself to transactions.
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a need investment, different employees, a different comprehensive model and approach. the problem with getting their is what we have today. my friend gave you his economic principle this morning. everybody wants to go to heaven but nobody wants to die. you have a lot of the two rated, well-financed, strongly held impediments to get in there. insurance companies with their models. there's also a very large cultural bias -- doctors who have been trained and have gotten comfortable practicing in a certain way for two-thirds of their career.
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to start doing things fundamentally differently. to get a broad wave movement of change across the country, it seems to me. you will only get there in some massive movement over a short amount of time if people are vents -- people are convinced there's not a practical alternative. if we have disin -- dis incentives. the deck is staccked again you. i think we need a cultural
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shift to say it is important for us in a real way to do something different. >> media have been writing stories about, sheers doctors and practices. people can afford them are flocking to them. >> if you are talking about economic model for people are fluent and have their own cost years person but if you can talk about leading a patient's needs, does not require that model. . some of the things we're doing
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right now -- we are bringing these into a team based practice that is very patient centered. problem is payment. the kinky somebody at a hospital in one of these teams based care systems but the patients have to every time.o-pay we do not have an economic and will be no different than
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the with the iphone disrupted the rca from the columbia music industry before. you have one economic model and somebody came in in was something different that was in need. when you get to the application status -- application state of things, you have to get a different system. the piece that will be important is you can have all those services. it is cheaper to the system but you have to tweak the pigment model preview half dozen global payments -- to tweak the payment. >> when you drill down into the concierge model, it is basically
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about access and in some areas, being able to find any primary care physician who will provide services to you. we have been able to provide that kind of access where people get into appointments. it takes having systems in place and the development of those systems across a large multi specialty group with a program of funding to make that work. so i did not see that being a long-term, large solution to the delivery issues we have. part of that is given by the lack of access to high-quality care which has been driven by the compensation system that has been part of medicine for the
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last 50 years with the low end primary-care services have not been valued by our system. if you do not value the services and did not come with a -- and do not compensate people to provide them. finding high-quality primary care as a matter of making it devalued -- matter of making it valued. >> you describe the 89-year-old woman who got the virus. this is not a typical example but i can think of many times when i wanted to see my primary care physician and there was no appointment available for weeks. your only option is to go to the emergency room.
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what went wrong and that your case? did she make the wrong choice? did the system set up the wrong transfer? are the physicians responsible for not a more available? kurds we were available. the weekend of christmas, it was my turn to work. we saw 95 patients. -- >> we were available. the weekend of christmas it was my turn to work. we saw 95 patients. it is -- it has to be incentivize. what we're doing in creating an economic model about access, at the works. in this situation, the patient or not used to it. -- the patient was not used to
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it. it would have been a different point of entry at our office. we knew her. we had access to records and we may not have treated her as aggressively. we do think that access is important. i would like to say something about the term primary-care physician. it was invented by a co-pay. i used to be called a general internist when i was in training. if you pay attention to what they call doctors, it is because we are getting ready to be changed the way we are paid. primary-care versus specialists have to do with one economic model to control costs. then it had to do with drg's and you created nocturnists. the specialist need to pay
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attention because they have changed their names again. they're being called proceduralists. that means that are getting ready to be whacked. a lot of times there is economic language underneath. term primary the care physician is such a bad thing because primary should be a good thing but it was not something i heard in training 20 years ago. i do not know what the solution is. but i do think we need to pay attention to what we call our doctors or other care providers. underneath, there is often
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economic assumptions. >> i am wondering how guilty building codes are for a lot of what has gone wrong. should that system be wiped out or revamped? it is an unbelievable number.
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